Category: Medical Claim Adjustments

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Medical Billing Guide Medical Claim Adjustments

Top Three Reasons Your Claim Has Been Denied

When it comes to medical billing, the coding network can get quite tricky. There are many reasons your claim may be denied. This fault could fall on the provider or the payer. The more informed you are, the easier the claim process will operate. It’s important to cooperate with your medical coding professionals and give them the most accurate information possible to avoid a denied claim. The best way to avoid errors is to communicate efficiently.

Having a claim error can negatively impact your practice and harm revenue cycles. To achieve an optimum experience with patients, it’s important to make this process seamless and smooth. We’ve all heard the “a bad foundation builds a weak house…” analogy. Think of your medical billing system in such a way. The well-being of your business is one of your main priorities. It’s essential to maintain a strong base of medical coding to keep everything on the front lines running as it should. At PractiSynergy, our highly trained staff works closely with you to build that foundation. This way you can get back to what’s important, rather than stressing about coding errors. 

Furthermore, we’re here to divulge common errors leading to claim denials. Using our years of experience, we’ve gathered our knowledge to reveal the top three reasons we see claims get denied – and how to avoid them. 

  1. Claims not filed on time
    • Provider contracts with Insurance companies dictate how long from the date of service a claim can be filed
    • Traditional Medicare is 1 year
    • Many insurers have drastically shortened time to 90-180 days
    • You can appeal denials with proof you filed on time – these appeals also must be filed timely
  2. No Authorization or Exceeded Authorization Denials
    • Providers must know which procedures require prior authorization from the insurance company
    • Most insurers allow providers to submit for emergency authorization when procedures must be done – or allow for post-service review and authorization
    • Most insurers DO NOT allow providers to bill patients if the provider neglected to get a prior authorization
    • The authorization typically states a time frame when the procedure must be completed as well as the number of procedures or visits allowed
    • Appeals may be done if there is documentation that information received from the insurance company stated an authorization was not required.
  3. Claim errors and patient demographic errors
    • Coding errors happen – but there are ways to minimize these errors by building edits or macros into a practice management system
    • Patient intake forms – these forms are typically filled out by patients. As these forms have become electronic they tend to feed directly into the practice management system. This causes an immense amount of error since most patients do not know exactly what information they need off an insurance card or they may put a nickname that does not match the insurance database
    • All demographics need to match what insurance companies have on file or there is a high probability of claims being rejected or denied

By making sure your claims are authorized, reported on time, and fully reviewed before submission, you’re able to avoid the most common faults we see as medical billing professionals. Taking these proper precautions can help the well-being of your practice and its backend process. 

Using this data, we’ve formulated our business in a manner to avoid such errors. We ensure our clients get none of the stress and all of the cash flow. When we work together we’re able to take the stress of coding errors off your back. Get back to what you do best. It’s our passion to help you, so you can help others. To get informed about our medical coding and billing services, Call Katie at PractiSynergy or reach out via Email. 

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Medical Claim Adjustments Medical Coding Guide

Deductible Season For All Medical Insurances

Doctor with health insurance healthcare graphic.

It’s here. Deductible Season. The time of year when most insurance plans re-set deductibles back to $0.

So, what exactly does that mean to your practice? Its not all doom and gloom, its not too late to make a few changes to help you maintain your cash flow.

1. Eligibility Check

Always check insurance eligibility. This includes MEDICARE! Medicare beneficiaries had open enrollment late fall allowing them to choose Medicare advantage plans as well as supplemental
plans. What do you want to look for when checking eligibility and verifying benefits?

a. Does the patient have an active policy? What is the effective date of that policy?

b. Does the patient have a co-pay, deductible, coinsurance, or an out-of-pocket maximum?

c. Does the service you provide require a prior authorization or a referral?

d. Does the patient have any secondary insurance?

2. Payment Collection

Collect payments from patients at the time of service. Unless an insurer bars you from billing a patient (such as Medicaid), it is wise to collect money up front. Always collect a co-pay at the time of service. If a patient has a deductible or co-insurance that applies to your service, collect a set amount of money at the time of service. Depending on your patient population and service provided anywhere between $50-$150 might be appropriate for your practice.

3. Don’t Make It Difficult To Pay For Patients

Always take a payment if a patient offers, and do not make it difficult for your patients to pay.

Technology is spanning all the generations. Patients regardless of age expect the ability to pay their bills online. Identity theft has increase and few patients want to send a check or credit card through the mail for fear it will be stolen. Secure email and text is a great way to remind your patients they still have a bill outstanding.

Finally, remind patients (verbally, in writing, or both) of their financial responsibility. Whether it is keeping insurance updated, patient contact information updated, and a friendly reminder that most insurers require the patient to pay the provider some portion of their bill – even Medicare (Medicare’s deductible for 2022 is $233).

These strategies will help medical practices keep a better cash flow during this deductible season. PractiSynergy can help providers set up these processes. Please contact Katie Fergus, call 515.412.2800 or email  katie@wordpress-799426-3758877.cloudwaysapps.com.

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Medical Billing Guide Medical Claim Adjustments

Claim Adjustments In Medical Billing

Claim Adjustments In Medical Billing - PractiSynergy

What are the adjustments codes do on the payers’ explanations of benefits and what do they mean? These codes tell the provider why all the money charged was not paid.

I have three categories for these adjustments: Contract Related, Process Related, and Patient Liability. From these categories, you should examine whether there is a payer error (not abiding by contracted rates or agreements), a billing error (something on the claim was not correct), or if the amount is owed by the patient

Payer Error and Contractual Adjustments:

  • The maximum amount was paid by the insurance company based on the contract the provider holds with the insurance company – This means what the amount charged by the clinic was more than the allowed reimbursement in the provider’s contract.
  • No prior Authorization – Provider contracts spell out the responsibility of the provider to acquire any prior authorization required by a policy or their payment may be reduced or denied
  • Billing Guidelines – claims may be denied due to the provider not following the proper rules to bill a particular medical procedure. For instance, providers may not be paid for cosmetic procedures. The definition of “cosmetic” is usually determined by a patient’s diagnosis coded and is spelled out in coverage documents for the plan. Providers are expected to review these and submit claims appropriately.

Medical Billing And Claim Adjustments

Billing Error and Process Related Adjustments:

  • Non-covered benefit – Providers are expected to check benefits for patients before they perform a procedure on a patient. Even a simple sick visit may be denied, or the payment may be reduced if an out of network provider give these services and the patient does not have out of network benefits. Another example may be when the insurance company expects a certain type of provider to perform a service (a physical therapist should not submit a claim for a throat culture for strep)
  • Patient does not have active coverage – Providers must verify a patient is eligible for their insurance as of the date the service will be provided. If the service happens before, after, or during a gap in coverage, the provider is not eligible for reimbursement from the insurance company. The beginning of the year is most common for these adjustments.
  • Incorrect coding – medical codes on a claim are critical to payment. Providers are ultimately responsible for which codes go on a claim. They may delegate this duty to certified coders to do a thorough job. Providers should always use current codes and not rely on Google to find the right code since there are many codes which are expired that swirl around cyberspace. For reliable codes please visit PractiSynergy.

Patient Responsibility:

  • Insurance companies may not pay a claim or only partially pay a claim if the patient has some cost-share responsibility. This may be in the form of co-pays, deductibles, or co-insurance. These amounts are deducted from the amount owed by insurance companies. Providers collecting these amounts up front would be best practice.
  • An insurance company may designate a patient owes the full amount charged if a provider is out of network or if the patient is not eligible for coverage on a particular date of service.

Providers should review these adjustment reasons on a regular basis to evaluate a payers’ performance (or the billing company performance). A quick check monthly on your most utilized procedure codes is also an easy way to make sure you are capturing all the revenue owed to you. PractiSynergy helps its clients with this analysis. Please contact Katie Fergus Call or Email to assist your practice review your payments and adjustments to make sure you are not missing any cash.